Lemierre-like syndrome presenting with extensive intracranial and central venous thrombosis without pulmonary embolism: illustrative case.

BACKGROUND: Lemierre-like syndrome is a rare septic thrombotic disorder caused by non-Fusobacterium pathogens. Presentations with predominantly intracranial involvement and extensive central venous thrombosis are particularly uncommon, and optimal management remains unclear. OBSERVATIONS: A 75-year-old female presented with impaired consciousness, fever, and right exophthalmos with conjunctival injection following mild sore throat. Contrast-enhanced CT demonstrated extensive thrombosis involving the superior vena cava, bilateral internal jugular veins, bilateral transverse-sigmoid sinuses, cavernous sinuses, and bilateral superior ophthalmic veins. There was no evidence of pulmonary embolism or septic pulmonary lesions. Brain MRI revealed right occipital venous infarction and marked cerebral venous congestion. Blood cultures yielded Streptococcus intermedius. Intravenous antimicrobial therapy and systemic anticoagulation were initiated immediately. Because antithrombin (AT) activity progressively decreased during the acute phase, adjunctive AT supplementation was administered. Serial MR venography demonstrated gradual recanalization, and the patient achieved favorable neurological recovery without hemorrhagic complications. LESSONS: Early recognition of Lemierre-like syndrome with predominant intracranial involvement and individualized multidisciplinary management may contribute to favorable neurological outcomes. https://thejns.org/doi/10.3171/CASE26541.